Provider Demographics
NPI:1588028278
Name:TREVICANO, AMANDA M
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:TREVICANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 BEACH 136TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLE HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1323
Mailing Address - Country:US
Mailing Address - Phone:917-440-6779
Mailing Address - Fax:
Practice Address - Street 1:221 BEACH 136TH ST
Practice Address - Street 2:
Practice Address - City:BELLE HARBOR
Practice Address - State:NY
Practice Address - Zip Code:11694-1323
Practice Address - Country:US
Practice Address - Phone:917-440-6779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026537235Z00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program